10 reasons why doctors over-order tests

by Neel Shah, MD

What are the top reasons doctors over-order tests?

1. How we’re taught
. Doctors are taught to consider whether a procedure is safe and whether it’s likely to work. We’re almost never taught to consider cost — it’s considered taboo.

2. Trying to do our best for the patient
. We’re worried. Often we over-order because of our personal risk aversion.

3. Pre-emptive ordering. For residents, who do much of the ordering of tests in hospitals, it may be more efficient to order tests now rather than later. Standard practice might be to order a relatively cheap screening test and then if it’s positive, order other expensive tests. Instead we sometimes just order everything at the same time so we don’t have to wait.

4. Covering all bases
. In medical culture, doing more is equated with being thorough. If there are five possible conditions that may explain a patient’s symptoms, and it’s probably going to be one or two of them, we might order tests for all five conditions right away.

5. General unawareness
. We just don’t know what things cost. When you talk to people and say, ‘Do you know a magnesium level is $70?’ it blows their mind.

6. Broader ignorance. It’s not doctors’ fault for being unaware. Health care costs tend to be very opaque, and many costs are very difficult to determine.

7. Not realizing how much setting affects cost
s
. An MRI in an emergency room setting can be twice the cost of an MRI for an outpatient.

8. Defensive medicine
. Doctors do fear malpractice claims, but the cost issue is far more complex than malpractice alone.

9. Patient requests
. Ultimately, we believe that good doctors should be at the service of their patients. Many patients, however, are not rational decision-makers. For most people, the current status of our health distorts how we value health care. Those of us who are healthy undervalue care and are less likely to see our primary care doctor. By contrast, those of us who are sick can overvalue care, sometimes even assuming significant debt for very marginal benefit.

10. Lack of oversigh
t. When administrators or insurance companies impose oversight of any kind that tries to limit doctors’ ordering, everyone tends to push back. Both doctors and patients are uncomfortable with the idea of a third party deciding how health care resources should be used.

Neel Shah is an obstetrician-gynecologist resident and can be reached on Twitter @CostsofCare.  This post originally appeared on
CommonHealth, and is reprinted with the author’s permission.

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  • family doc

    Patients that have “skin in the game” due to high deductible plans provide plenty of oversight and ask appropriate questions when I order tests. If we stop paying for most medical care with other people’s money, these problems would be greatly reduced.

  • Indian Doc

    Recently one of my friends a Paediatrician was successfully sued for misssing a diagnosis of Coeliac Disease.The patient was very poor and was being treated for free.He had frequent Diarrhoea,for which he was treateds twice.Since my friend works in a small hospital with minimal facilities he asked for a workup in a specialsed centre.The diagnosis was done after patient was admitted for a month in a speciaslised hospital.The father thinks doctor should pay for this delay/error,the idiot masquerading as judge agreed without taking an expert opinion

  • http://www.costsofcare.org Neel Shah

    Family Doc, if you have a story that illustrates the difference between patients with “skin in the game” and those who don’t we would love to hear it. http://www.costsofcare.org/essay

  • family practitioner

    One more:
    We are incentivized to do more; if we order tests, it ups our medical decision making, a 99213 can become a 99214 and a 99214 can become a 99215.

  • http://www.davisliumd.blogspot.com Davis Liu, MD

    Trying to do our best for the patient. Covering all bases. Patient requests. All reasons given for overtesting, but also all within a doctor’s control not to fall for these traps.

    Doing best for patient means knowing when to ask colleagues for an opinion or a specialist (primary care or specialty care) rather than over order testing because of personal risk aversion. If you aren’t sure, ask someone who does.

    Covering all bases means the same as above. If you have five possibilities, it is highly unlikely all five have equal likelihood and weighting. If you over order now, you will undoubtedly get many false positives which require even more unnecessary additional testing and driving costs further. Anyone can order tests. Great doctors can tell what is truly needed and what tests aren’t.

    Patient requests. Patients know what they want; they want to get better or stay healthy. What they don’t know is necessarily how to get there. Do you simply order tests like MRI for knee pain or a treadmill for chest discomfort because they request it or do you evaluate them, talk them down from the request if not appropriate or needed, and focus what they really want? Yes, sometimes you need to order a test because a patient requests it. If that is the case, call out the test result before ordering it. “Yes I know that your chest pain is highly unlikely and a treadmill isn’t necessary. Because you are so worried, I will order it for you. Incidentially, it will be completely normal. Really. Completely normal. So before you leave, would you like me to treat your chest pain which is actually heartburn or would you like to suffer with your symptoms while we wait for you to get the test done?”

    I agree both doctors and patients are reluctant to have third parties determine what is and isn’t necessary. Until doctors take the charge of ordering appropriate testing (and I realize that the reimbursement structure as it stands makes it impossible to do the right thing and hence the rise of high deductibles / copays so patients now ask you if you are doing the right thing), one can only expect healthcare costs to rise and doctors to over test.

    In the end, are you (not the author of the post specifically) a doctor’s doctor, someone who is gifted and skilled enough to figure out when testing is needed and when it isn’t or are you simply ordering a bunch of tests and trying to rationalize other reasons for the behavior?

    • Alina

      Very well said, Dr Liu. Finally a voice of reason!

  • http://www.tjgmd99.wordpress.com Thomas Gerke, M.D.

    great summary..some observations..
    do NOT order a test unless you are prepared to deal with the results…tests should be done to confirm a clinical suspicion….history,,,history…history…the patient will tell you what is wrong id you ask the right questions…always do what is in the patient’s best interest…

  • John

    With malpractice awards at times exceeding $10 million, the costs of scans or labs no longer impress me. Although the history and physical exam are important, they cannot detect the disease or injury that is easily found by scan or labs. Society expects a healthcare system that delivers nearly 100% accurate diagnoses. One mistake and the “physician’s physician” could become the “indentured servant” for the remainder of his/her lifetime.

  • http://diagnosticinformationsystem.com Bob Coli, MD

    Dr. Shah,
    One other major reason for doctors ordering duplicate, redundant and non-contributory tests is the continued use of variable paper and electronic formats to report cumulative test results as fragmented, incomplete and hard-to-read data.

    The simple solution is standard format that displays clinically integrated, complete and easy-to-read information on up to 80 percent fewer screens and pages.

    Eventually, in the emerging collaborative care era, competing vendors of EHR, PHR, CLIS and HIE platforms and physician and patient portals seeking high usability to differentiate their brands will catch on and catch up with this unmet physician need.

  • gzuckier

    Also; high popularity of the TV show, “House”.

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